Tony Dodek, MD · Linking Quality and Efficiency The 2011 AQC ensures that providers have a strong...

Session 7

Health Plans and Quality

Tony Dodek, MD August 11, 2015

Practicing Medicine in the Era of Health Reform

Tufts Health Care Institute

Agenda

Overview of nationally recognized organizations in quality measurement

Performance Measurement: Framework, Principles and Pitfalls

“Real World” example of quality measurement: BCBSMA’s Alternative Care (AQC) contract

NATIONALLY RECOGNIZED ORGANIZATIONSIN QUALITY MEASUREMENT

National Quality Forum• Multi-stakeholder, private, non-profit organization with over 375 members representing every aspect of healthcare delivery system.

• Sets national priorities and goals for performance improvement.

• Endorses national consensus standards for measurement and publicly reports on performance.

• Promotes the attainment of national goals through education and outreach programs.


Agency for Healthcare Research and Quality• Agency within the Department of Health and Human

Services whose mission is to improve the quality, safety, efficiency, and effectiveness of health care.

• Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care.

• Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions.

• Efficiency: Transform research into practice to facilitate wider access to effective health care services and reduce unnecessary costs.


Choosing WiselyABIM initiative in conjunction with Consumers’ UnionIdentification of five tests/procedures within each

medical specialty whose necessity should be questioned or discussed70 medical specialties participatingExample: “Don’t do imaging for low back pain within

the first six weeks unless red flags are present”(American Academy of Family Physicians)


National Committee for Quality Assurance• Private, non-profit organization that develops quality

standards and performance measures for a variety of healthcare organizations

• The annual reporting of performance against such measures has become a focal point for the media, consumers, and health plans, which use these results to set their improvement agendas for the following year.

• Seven accreditation programs, five certification programs and five physician recognition programs.

8

15%

60%

25%

NCQA & National Rankings: 3 Components

CAHPS, HEDIS, and the NCQA Survey each impact health plan accreditation status and national ranking.

NCQA Accreditation(2013-2015) National Ranking

50%

37%

13%

CAHPS HEDIS STANDARDS SCORE

NCQA Accreditation(2007-2010)

64%

23%

13%

Measurement Pitfalls

Your safer-surgery survival guide“For the first time ever, Consumer Reports has surgery ratings for 2,463 hospitals across the country, based on the percentage of a hospital's surgery patients who died in the hospital or stayed longer in the hospital than expected for their procedure. See how the hospitals in your community fared.”

Measurement Pitfalls

Using that data, the authors of the Consumer Reports rating “do a disservice if they put information out there that misclassifies hospitals,” said Dr. Elizabeth Mort, chief quality officer at Massachusetts General Hospital, which was rated poorly.Mort said she has concerns about whether the rating accurately accounts for patient volume or the severity of patients’ illnesses, something that is more accurately captured in medical records than in billing data. She also said the rankings may have grouped surgical procedures together that have varying degrees of expected complications, reflecting poorly on those hospitals that do the more complex treatments.

11Blue Cross Blue Shield of Massachusetts

Guiding Principles in Selecting Performance Measures for “High Stakes” Use

Wherever possible, measures should be drawn from nationally accepted standard measure sets.

The measure must reflect something that is broadly accepted as clinically important.

There must be empirical evidence that the measure provides stable and reliable information at the level at which it will be reported (i.e. individual, site, group, or institution) with available sample sizes and data sources.

There must be sufficient variability on the measure across providers (or at the level at which data will be reported) to merit attention.

There must be empirical evidence that the level of the system that will be held accountable (clinician, site, group, institution) accounts for substantial system-level variance in the measure.

Providers should be exposed to information about the development and validation of the measures and given the opportunity to view their own performance, ideally for one measurement cycle, before the data are used for “high stakes” purposes.

Quality Measurement in the “Real World”: BCBSMA’s Alternative Quality

Contract (AQC)


Alternative Quality Contract

Context for AQC Development

Overview of AQC Model

AQC Results: The First Four Years

AQC Support and Improvement Analytics

Local and National Policy Context


Context for AQC Development


Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

Source: OECD Health Data 2011 (Nov. 2011).

Economic Imperative in a Global Economy

16Blue Cross Blue Shield of Massachusetts Proprietary and Confidential – Do Not Distribute without Permission

US

A

MA

AK CT

ME

DE

NY RI

NH

ND

PA

WV VT NJ

MD

MN WI

FL OH

SD

NE

WY

MO IA HI

LA KS

KS IL IN NM MT MI

KY

OR

MS

OK

NC TN SC

VA AL

CA

AR

CO TX NV ID GA AZ

UT

Massachusetts spends more on health care than any other state in the country

*Personal health care expenditures (PHC) are a subset of national health expenditures. PHC excludes administration and the net cost of private insurance, public health activity, and investment in research, structures and equipment. Source: CMS Office of the Actuary

USA: $6,815

MA: $9,278

PA: $7,730OH: $7,076

MI: $6,618 VA: $6,286

UT: $5,031

Per capita health care expenditure by state in 2009 dollars*

17Blue Cross Blue Shield of Massachusetts Proprietary and Confidential – Do Not Distribute without Permission

The increasing cost of health care in MA compared to other public spending priorities

STATE BUDGET, FY2001 VS. FY2014 (BILLIONS OF DOLLARS)

FY2014FY2001

+$5.4 B(+37%)

-22% -31%

-12%

-14%

-11%

-51%

-13%

-$3.6 B(-17%)

Health Coverage(State Employees/GIC;

Medicaid/Health Reform)

PublicHealth

MentalHealth

Education Infrastructure/Housing

HumanServices

LocalAid

PublicSafety

Source: Health Policy Commission, 2013 Cost Trends Report, data from the Massachusetts Budget and Policy Center


The Massachusetts health reform law (2006) caused a bright light to shine on the issue of unrelenting double-digit increases in health care spending growth (Health Care Reform II).

The Alternative Quality Contract: Twin goals of improving quality and slowing spending growth

In 2007, leaders at BCBSMA challenged the company to develop a new contract model that would improve quality and outcomes while significantly slowing the rate of growth in health care spending.

8.2%

15.9%

13.8%13.1%

12.1%

13.3%

12.8%

12.5%

10.8%

10.7%

-2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

BCBSMA Medical Trend Workers' Earnings General Economic Growth

Sources: BCBSMA, Bureau of Labor Statistics.


The AQC Model


Global Budget• Population-based budget

covers full care continuum

• Health status adjusted

• Based on historical claims

• Shared risk (2-sided)

• Trend targets set at baseline for multi-year

Quality Incentives• Ambulatory and hospital

• Significant earning potential

• Nationally accepted measures

• Continuum of performance targets for each measure (good to great)

Long-Term Contract• 5-year agreement

• Sustained partnership

• Supports ongoing investment and commitment to improvement

The Alternative Quality Contract


AMBULATORY HOSPITALPROCESS • Preventive screenings

• Acute care management

• Chronic care management• Depression• Diabetes• Cardiovascular disease

• Evidence-based care elements for: • Heart attack (AMI)• Heart failure (CHF)• Pneumonia• Surgical infection prevention

OUTCOME • Control of chronic conditions• Diabetes • Cardiovascular disease • Hypertension

***Triple weighted***

• Post-operative complications• Hospital-acquired infections• Obstetrical injury• Mortality (condition –specific)

PATIENT EXPERIENCE

• Access, Integration• Communication, Whole-person

care

• Discharge quality, Staff responsiveness• Communication (MDs, RNs)

EMERGING Up to 3 measures on priority topics for which measures lacking

AQC Measure Set for Performance Incentives


Performance Payment Model: Updated (2011)As quality improves, provider share of surplus increases/deficit decreases

1.0 2.0 3.0 4.0 5.0

PMPM Quality DollarsThe 2011 AQC also allows groups to earn PMPM quality dollars regardless of their budget surplus or deficit. High quality groups earn more PMPM quality dollars.

Linking Quality and EfficiencyThe 2011 AQC ensures that providers have a strong incentive to focus on both objectives.

20%40%

70%

80%

Quality Performance IncentiveProvider Share of Surplus (increases as quality improves)Provider Share of Deficit (decreases as quality improves)

55%

Performance Score

PMPM


AQC Results: The First Four Years


2,577 2,618

5,065

11,73112,986

14,06714,777

02,0004,0006,0008,000

10,00012,00014,00016,000

2009 2010 2011 2012 2013 2014 2015*

SCPs

1,373 1,420

2,303

4,592

5,1365,547 5,664

0

1,000

2,000

3,000

4,000

5,000

6,000

2009 2010 2011 2012 2013 2014 2015*

PCPs

AQC Physician Participation(Current as of February 2015)

90% 93%

* All 2015 figures as of February


Results Under The AQC:Improvement of the 2009 Cohort of AQC Groups from 2007-2012

Opt

imal

Car

e

These graphs show that the AQC has accelerated progress toward optimal care since it began in 2009. The first two scores are based on the delivery of evidence-based care to adults with chronic illness and to children, including appropriate tests, services, and preventive care. The third score reflects the extent to which providers helped adults with serious chronic illness achieve optimal clinical outcomes. Linking provider payment to outcome measures has been one of the AQC’s pioneering achievements.

83.1 84.086.0 86.7

80.4 81.1 80.8 81.077.7

79.6

79.2 80.3

2007 2012

BCBSMA HEDIS National Average

Adult Chronic Care

Pediatric Care

91.3 91.6 92.2 92.1

69.7 70.7 71.6 71.7

88.289.9

68.1 69.5

2007 2012


Adult Health Outcomes

65.668.3

72.2 74.0

61.4 61.9 62.2 61.9

61.5 62.1

59.8 61.2

2007 2012


100

50


AQC Results: Formal Evaluation Findings

Source: Song Z, et al. Changes in Health Care Spending and Quality 4 Years into Global Payment. The New England Journal of Medicine. 2014.


Total Cost Results

• The Harvard evaluation documented that AQC is reducing medical spending, but accounts also want to see reductions in total spending

• By Year-3, BCBSMA met its goal of cutting trend in half (2 years ahead of plan)

• By Year-4, BCBSMA total cost trend was below state general economic growth benchmark (<3.6%)

AQC Total Cost Increases (FFS + incentives)


AQC Support & Improvement Analytics


Components of the AQC Support Model

Our four-pronged support model is designed to help provider groups succeed in the AQC.

Data and Actionable Reports

Best Practice Sharing and Collaboration

Consultative Support

Training and Educational Programming


Daily Daily Census, Discharge, PCP Referrals and

Inpatient & Outpatient Authorization ReportsWeekly New Member Report ED Utilization ReportMonthly AQC Member Call Tracking Grid Monthly Ambulatory Quality Report Monthly AQC Ambulatory Quality Measures

Group Comparison Report Chronic Condition Opportunities Report Quality Diabetic Composite Score Bi-Monthly Case Management Report

Quarterly Ambulatory Care Sensitive Conditions Report AQC Financial Dashboard Non-Emergent ED Report Top 100 Rx ReportBi-Annually Practice Pattern Variation Report—Episode

Treatment Groups (ETG) Practice Pattern Variation Report—Emergency

Department Use for Specific ConditionsAnnually Readmission Report AQC Ambulatory Quality Measures Score/Results AQC Hospital Quality Measures Score/ResultsRecurring Cost and Use Report Site of Service Report

Data and Actionable Reports

We distribute reports that can be used to help organizations recognize opportunities, develop goals and measure their success.


The results are highly actionablebecause they get to the root of variations in treatment costs for a defined and highly-specific clinical circumstance among physicians of the same specialty

Source: Greene RA, et al. Health Affairs 2008; w250-259

Practice Pattern Variation Analysis (PPVA)

Unpacking differences in the treatment components of specific episodes across clinicians in a single, defined medical specialty.


The 12 primary care physicians in this group have rates of ARB use ranging from 13% to 55%.

9 physicians have rates above the network average.

Benign Hypertension, With and Without ComorbidityIndividual Primary Care Physicians

Rate of ARB Use per 100 Episodes with ACE-I and/or ARB2007

Rate = Episodes with ARB / Episodes with ACE-I and/or ARB

0

10

20

30

40

50

60

70

80

90

100

1 355 709 1063 1417 1771 2125 2479 2833

Individual Primary Care Physicians (N=3178)

Rat

e of

AR

B U

se p

er 1

00 E

piso

des

with

AC

E-I a

nd/o

r AR

B

The 12 primary care physicians in this group have rates of ARB use ranging from 13% to 55%.

9 physicians have rates above the network average.


Tendency to Use Upper GI Endoscopy: Group Example


MMS “Suggested Guidelines for Endoscopies for Gastroesophageal Reflux Disease (GERD)”


15

16

17

18

19

20

21

22

23

24

25

2009 2010mid 2011mid 2012mid 2012 2013mid

Rat

e of

Upp

er G

I per

100

Epi

sode

s

PPVA Measurement Period

Inflammation of the Esophagus, without surgeryRate of Upper GI Endoscopy per 100 Episodes

PCPs and their HMO/POS Member Panel ExperienceProvider Group XYZ vs Network Average across Measurement Periods 2009 to mid 2013

Provider Group XYZNetwork Average

Change in Performance Over Time:Rate of Upper GI Endoscopy per 100 Episodes


0

20

40

60

80

100

1 65 129 193 257 321 385 449 513 577 641 705

PCP Groups (N=767)

Rat

e of

Ref

erra

l to

Ort

hope

dic

Surg

eon

or N

euro

surg

eon

per 1

00 E

piso

des

- The 21 PCP groups associated with XYZ have referral rates to orthopedic surgeons and neurosurgeons ranging from 0 to 35 per 100 episodes.

- 3 groups have a rate of 0.

- 9 groups have rates at or above the network average.

Low Back Pain as subset of Joint Degeneration of the Neck & Back, with & without surgery

Med Grp XYZ PCP GroupsRate of Referral to Orthopedic Surgeon or Neurosurgeon per 100 Episodes

2006 - 2007

Rate = Episodes with at least 1 Referral to Ortho. Surg. or Neurosurg. / Total Episodes per PCP Group

Variation in PCP referral for Low Back Pain


0

50

100

150

200

250

300

350

400

450

500

1 65 129 193 257 321 385 449 513 577 641 705

PCP Groups (N=720)

Ave

rage

# o

f Day

s fr

om In

itial

Vis

it to

MR

Low Back Pain as subset of Joint Degeneration of the Neck & Back, with & without surgery

Medical Group XYZ's PCP GroupsAverage # of Days from Initial Visit to MRI

2006 - 2007

Rate = Sum of Days from Initial Visit to MRI / # of Episodes with MRI per PCP Group

- The 21 PCP groups associated with Medical Group XYZ have average days between initial visit and MRI ranging from 0 to 311 days.

- 12 PCP groups have average days less than the network average.

- The same 12 PCP groups also have average days less than 6

Variation in Days-to-MRI for Low Back Pain


Change in Performance Over Time:Rate of MRI per 100 Episodes for Low Back Pain

15.0

17.0

19.0

21.0

23.0

25.0

27.0

29.0

31.0

33.0

35.0

2009 2010mid 2011mid 2012mid 2012 2013mid

Rat

e of

MR

I Use

per

100

Epi

sode

s

PPVA Measurement Period

Low Back PainRate of MRI per 100 Episodes

Groups of PCPs and their HMO/POS PanelProvider Group ABC vs Network Average across Measurement Periods 2009 to mid 2013

Provider Group ABC

Network Average


Summary and Priority Issues Ahead

Summary

Payment reform gives rise to significant delivery system reform

Rapid and substantial performance improvements are possible in the context of: Meaningful financial incentives Rigorously validated measures & methods Ongoing and timely data sharing and engagement Committed leadership

For payment reform, deep provider relationships and significant market share are advantageous For national payers, remote provider relationships pose

engagement challenges; member-facing incentives (benefit design) an attractive lever

Priority Issues Ahead

Expanding payment reform to include PPO presents unique challenges Gaining strong employer buy-in & support will be important;

and this means models must offer value from day-1

Continued evolution of performance measures to fill priority gaps Focus on outcomes, including patient reported outcomes

(functional status, well being)

Continued evolution of the delivery system: Evolving the role of hospitals in the delivery system Building deeper engagement of specialists Bringing incentives (financial & non-financial) to front lines Advancing innovations in virtual care

Payment incentives to front line clinicians need continued attention

Tony Dodek, MD · Linking Quality and Efficiency The 2011 AQC ensures that providers have a strong...

Documents

Transcript of Tony Dodek, MD · Linking Quality and Efficiency The 2011 AQC ensures that providers have a strong...